Background Rationale & hypotheses Findings Conclusions

1. CTN MIEDAR Studies Baseline Comparison: Methadone vs Psychosocial ParticipantsMaxine Stitzer, Ph.D.AAAP December, 2003 • Background • Rationale & hypotheses • Findings • Conclusions

2. Drugs are Positive Reinforcers They Make People Feel Good.

3. The Problem: Allure of Immediate Drug Reinforcement

4. Abstinence Continued Use Drug Abusers Straddle the Fence

5. Methods are needed to: Drug Abstinence Continued Drug Use - counteract ambivalence- increase motivation for change

6. Motivational Incentives Offer tangible incentives for drug abstinence Make abstinence a more attractive option through positive reinforcement of behavior change

7. Incentive Therapies Promote Abstinence • Cocaine • (Higgins et al., 1994; Silverman et al., 1996; Petry & Martin, 2002) • Alcohol • (Petry et al., 2000) • Opioids • (Bickel et al., 1997; Silverman et al., 1996) • Marijuana • (Budney et al., 1991, Budney et al., 2000) • Nicotine (Tobacco smoking) • (Stitzer & Bigelow, 1984; Roll et al., 1996)

8. Problem: Cost • Society can’t afford this • Our program can’t afford this

9. Intermittent Reward Reduces CostNancy Petry’s “Fishbowl” • Drug-free patient draws from the “fishbowl” • Only 50% of draws are “winners” • Three types of prizes: - small (toiletries; food) - large (cordless phone; CD player) - jumbo (TV; video)

10. CTN MIEDAR Protocol: How Does It Work?

11. Eligible Patients • Stimulant Abusers • either cocaine or methamphetamine

12. Random Assignment • Usual care • Enhanced care with incentives

13. Sample Collection Twice Weekly

14. Good Job Abstinence Bowl Small Good Job Jumbo Large Small Small Large Small Good Job Good Job Good Job Good Job Good Job Good Job Good Job Small

15. Examples ofIncentive Prizes SMALL ($1-$5 items) JUMBO ($80-$100 items) LARGE ($20 items)

16. Draws Escalate with Stimulant-Free Test Results 5 4 # Draws 3 2 1 Weeks Drug Free

17. Bonus Draws for Marijuana and/or Opiate Abstinence # Draws 2 2 2 2 2 Weeks Drug Free

18. Total Earnings • $400 in prizes could be earned on average • If participant tested negative for all targeted drugs over 12 consecutive weeks

19. Two MIEDAR Study Samples • Psychosocial (8 clinics; N = 415) • New admissions • Self-reported stimulant use within past 2 weeks (74%) or within 2 weeks of entering a controlled environment (23%) • Methadone (6 clinics; N = 388) • In treatment 1-36 months • Stimulant positive urine within past 2 weeks

20. Baseline Comparison: Why Do IT? • Unique opportunity to characterize stimulant abusers entering different modalities • Results may suggest differential service needs

21. Baseline Comparison: Methods • Data derived from selected questions in study intake interview • Areas of interest: • Demographics • Psychosocial characteristics (employment, education, etc) • Health problems(medical & psychiatric) • Drug use (stimulants, opiates, alcohol, cannabis)

22. Hypotheses • Some patient characteristics may differ due to differential referral patterns (e.g. criminal justice) • Methadone patients will generally have more severe psychosocial and drug use problems due to their history of concurrent opiate and stimulant abuse

23. METH (N = 388) PSOC (N = 415) P value Gender (% male) 56 45 <.01 Race (% Caucasian) 26 36 <.01 Age (mean years) 42 36 <.01 Basic Demographics Subsequent analyses adjusted for gender, race & age

24. Psychosocial Characteristics

25. METH PSOC OR† CJ referral (%) 6 33 0.1 Parole/Probation (%) 16 35 0.3 Legal Status †OR is methadone vs drug-free

26. Health Problems

27. Drug Use: Stimulants PSOC METH OR Dependence/Abuse (% with diagnosis) 82 84 ___ First Study Urine 76 26 7.8 (% positive)

28. Drug Use: Opiates METH PSOCOR Dependence/Abuse (% with diagnosis) 80 9 48 First Study Urine (% positive) 47 3 30

29. Drug Use: Alcohol METH PSOCOR Dependence/Abuse (% with diagnosis) 17 42 0.3 First Study BAL (% positive) 1 1 __

30. Drug Use: Cannabis METH PSOCOR Dependence/Abuse (% with diagnosis) 8 21 0.5 First Study Urine (% positive) 12 11 __

31. Drug Use: Other ASI past 30 days; % with any use SEDATIVES METHPSOC 25 6 NICOTINE METH PSOC 91 79

32. Data Summary • Stimulant abusers entering methadone are: • Older • Less likely to have work history • More likely to have medical problems • More likely to be using opiates, stimulants & sedatives • Less likely to be alcohol or cannabis dependent

33. Data Summary • Both groups have: • Substantial unemployment • Substantial psychiatric co-morbidity • High rates of medical problems • High rates of nicotine use • Modest rates of cannabis use

34. Limitations • Data apply only to stimulant abusers • Clinics may or may not be representative • Methadone have been in treatment longer • Methadone are pre-selected for opiate abuse

35. Conclusions: Service Needs • Common service needs suggested: • Employment; co-occurring medical & psychiatric • Shift in emphasis from cannabis to nicotine • Differential service needs suggested: • Effective interventions for on-going polydrug (opiate, stimulant and sedative) use in methadone • Relapse prevention in outpatient psychosocial

36. Conclusions: CTN Potential • CTN is a great place to collect data on large samples of community treatment patients • Access to special patient subgroups of interest to service providers